Applied behavior analysis in the treatment of post-traumatic stress disorder (PTSD) has been shown to increase patients’ ability to manage trauma-related emotions, thereby allowing them to achieve more confidence in their ability to cope, control emotions and avoid lashing out and engaging in self-destructive behaviors.

The National Center for PTSD (part of the U.S. Department of Veterans Affairs) estimates that under normal socio-economic-political conditions, about 8 percent of the U.S. population will experience PTSD at some point in their lives, with women about twice as likely as men to develop PTSD. It is also estimated that because of ongoing turmoil worldwide, it is likely that the incidences of PTSD will sharply increase, making it one of the most pressing public health concerns of this century.

One of the largest populations with PTSD remains veterans. PTSD affected more than 20,000 U.S. military service members in 2013 alone. Statistics show that PTSD affected more than 150,000 service members since 2000.

Causes, Symptoms and Aggravating Factors

Post-traumatic stress disorder is categorized as a mental health condition that usually results from experiencing or witnessing a life-threatening event. While it is normal to have upsetting memories or trouble sleeping following a traumatic event, those with PTSD have lingering symptoms (usually longer than a few months). For some people, PTSD symptoms may not occur right away (sometimes months or years later), while for others, symptoms may come and go.

PTSD can happen to anyone, although those who have experienced a very intense or long-lasting traumatic event are more likely to develop it. It is more common after certain types of trauma, such as sexual assault and combat.

Considerable research has been done on PTSD in recent years, particularly among victims of:

Terrorism

War trauma (veterans)

Sexual assault/sexual abuse

Road traffic accidents

Natural and manmade disasters

PTSD is also often observed as a comorbidity of other psychiatric disorders, including depression, anxiety disorders, schizophrenia, and borderline personality disorder, and there is a greater likelihood of drug and alcohol abuse among those with PTSD.

The PTSD syndrome is an amalgamation of cognitive, behavioral, and psychological disturbances that can cause great distress and interfere with work and home life. Most PTSD models are characterized by a four-symptom cluster:

Reliving the event: Bad memories or nightmares make those with PTSD feel as if they are reliving the event again and again.

Avoiding situations that trigger memories of the event: People with PTSD attempt to avoid any situation they feel might trigger memories of the traumatic event.

Experiencing negative beliefs and feelings: Feelings of guilt or shame, lacking interest in activities once enjoyed, and feeling numb are some of the feelings experienced by those with PTSD.

Feeling keyed up or anxious: Patients with PTSD may be jittery, always on alert, and have difficulty concentrating or seeping. They may also start easily or become easily irritable or angry.

According to the American Psychiatric Association, symptoms of PTSD last longer than 4 weeks.

A considerable amount of research exists to support cognitive and behavioral interventions for the treatment of PTSD, with exposure therapy being the most frequently utilized. Contemporary treatment for PTSD focuses on exposure, which is based on the idea that anxiety lessens through a process of continued exposure to the thoughts of the trauma.

Although the success of exposure therapy is well-established, concerns exist regarding the use of this therapy in real-world settings.

These limitations have opened the door for other effective PTSD interventions, including acceptance and commitment therapy, dialectical behavior therapy, functional analytic psychotherapy, and behavioral activation. Behavioral activation, known as the third generation of behavior therapy, is a functional analytic psychotherapy rooted in applied behavior analysis.

It is because of the lack of success in exposure therapy that the third wave of behavior therapies are proving to be effective in the treatment of PTSD. While exposure-based therapies focus on eliminating emotions based on the trauma, behavior therapies focus on helping clients explore the reason they are avoiding behaviors.

The fact that PTSD is often recognized as a reaction to some event that triggers a painful memory followed by a response that may range from explosive anger to substance abuse as a means of escape or avoidance, makes it a perfect candidate for the application of the so-called ABCs of applied behavior analysis: Antecedent, behavior, and consequence.

Behavioral activation (BA) involves a functional analysis of the client’s behavior and the development of a treatment plan focused on addressing the behavior to encourage more active behaviors.

Applied behavior analysts help PTSD clients engage in active behaviors to accomplish their goals. Because avoidance is a key symptom of PTSD, applied behavior analysts encourage individuals with PTSD to assess their environment and be aware of any indication of trauma-related signals, including their emotional responses. Applied behavior analysts then target their clients’ avoidance responses through the implementation of specific activities or behaviors.

For example, PTSD patients often pull away or avoid situations they used to find enjoyable or meaningful. Withdrawal and avoidance makes PTSD worse and often leads to depression. Through BA, applied behavior analysts help individuals with PTSD become active in their life again, either by restarting activities or finding new, meaningful activities. BA helps patients with PTSD identify the things in their lives that are stopping them from living the life they want to lead.

BA goals include focusing on targeted efforts to improve health (e.g., re-establishing fitness routines), pursue academic or career goals (e.g., enroll in college or apply for jobs), and improve, re-establish, or develop personal relationships. Applied behavior analysts help PTSD patients identify weekly tasks that represent steps toward their goals. Afterwards, they ask patients to identify avoidance behaviors that are interfering with the completion of assigned tasks and problem-solve ways to overcome avoidance, often through alternate coping strategies.

A general course of BA for PTSD includes:

Orientation to the treatment

Identifying psychological distress and primary treatment strategies

Developing treatment goals

Performing behavior analyses

Repeating activation and engagement strategies

Troubleshooting

Reviewing treatment and putting relapse prevention strategies in place

An August 2010 study conducted by the International Society for Traumatic Stress Studies examined the treatment-satisfaction and potential therapeutic benefits of using BA as a treatment for veterans of the Iraq and Afghanistan Wars with PTSD and depression. Eight veterans were given 5-8 weekly sessions of BA in a post-deployment primary care clinic. The study found “significant and meaningful” reductions in PTSD symptoms on clinical assessments and self-report measures. These results were maintained at the three-month follow-up.

According to the study’s authors the majority of veterans in this study “demonstrated meaningful improvements” regarding their quality of life and satisfaction with the treatment.